Office of Medicare Hearings and Appeals (OMHA)

Appeals of Entitlement and Premium Issues

Often the Social Security Administration (SSA) and the Centers for Medicare and Medicaid Services (CMS), the Federal agency that administers the Medicare program, make decisions regarding Medicare benefits and beneficiaries that are not medical in nature and are unrelated to coverage of and payment for medical services and items. This section describes the appeal processes for two issues of this nature.

Appeals involving Entitlement to Medicare Benefits

OMHA hears appeals of decisions from the SSA that an applicant is not entitled to be a beneficiary of the Medicare program. The local SSA office makes the initial decision about whether an applicant is entitled to Medicare benefits and on what terms. SSA may then conduct a reconsideration of that decision.

If your application for Medicare benefits under any part of the Medicare program is denied, you will receive a notice of your rights to appeal that decision to the Office of Medicare Hearing and Appeals (OMHA).

Appeals involving Determinations of the Income Related Monthly Adjustment Amount (IRMAA) to Medicare Part B Insurance Premiums

OMHA hears appeals of the Medicare program’s determination of a beneficiary’s IRMAA, which determines a Medicare beneficiary’s total monthly Part B insurance premium. The Part B insurance premium is set annually by the CMS. Prior to January 2007, the Federal Government provided a 75% premium subsidy and Part B beneficiaries paid only 25% of the insurance premium (the standard premium amount). Effective January 1, 2007, Part B beneficiaries with incomes above a certain threshold amount (about 4% to 5% of all Part B beneficiaries) are subject to an adjustment of the amount of the premium that they must pay for Part B insurance. The IRMAA is based on information from the individual’s income tax return obtained from the Internal Revenue Service (IRS) and calculated according to a mathematical formula established by law. The IRMAA is then added to the standard premium amount to calculate the beneficiary’s total monthly Part B insurance premium. SSA notifies a beneficiary of his or her Part B insurance premium and any IRMAA with the beneficiary’s annual notice of Social Security benefits (referred to as an initial determination). SSA is responsible for issuing all initial and reconsideration determinations.

There are limited situations that may qualify a beneficiary for a new initial determination:

If a beneficiary filed an amended tax return for the year SSA is using to make an IRMAA decision;
If there is an error in the IRS data;
If the IRS provided SSA with older data and the beneficiary wants to use newer information;
If an IRMAA decision was processed using tax filing status “married – filing separately” but the beneficiary lived apart from his or her spouse all year; or
If the beneficiary had a qualifying life-changing event that significantly reduced his or her modified adjusted gross income (MAGI).

If the beneficiary has a qualifying life-changing event that affects the beneficiary’s MAGI, the beneficiary may request a redetermination of the IRMAA. There are seven qualifying life-changing events:

Death of spouse
Marriage
Divorce or annulment
Work reduction
Work stoppage
Loss of income from income producing property
Loss or reduction of certain kinds of pension income

Events that result in the loss of dividend income or affect a beneficiary’s expenses, but do not affect a beneficiary’s income, are not considered qualifying life-changing events.

As a beneficiary, you have the right to appeal if you believe that an IRMAA is incorrect for one of the qualifying reasons. First, you must request a reconsideration of the initial determination from SSA. A request for reconsideration can be done orally by calling the SSA 800 number (800.772.1213) as well as in writing to SSA.

If you are dissatisfied with SSA’s reconsideration determination, you may request further review, including a hearing before an OMHA Administrative Law Judge (ALJ). If you are dissatisfied with the ALJ’s decision, you can proceed to Level 4 of the Medicare appeals process and on to Level 5 of the appeals process if you remain dissatisfied with the IRMAA determination.